Background: Malaria has remained a major public health burden in Malawi despite recent global progress in its control. Children under the age of five and pregnant women are among the groups most affected by the disease. Malaria research has been identified to provide vital evidence that contributes to addressing this burden through the development of evidence-based policies. One of the challenges however, is the lack of a systematic mechanism through which malaria research can be fully utilised for policy development. Unless research is commissioned by the government, individual researchers often do not know the pathway through which they can engage with policymakers. While some institutions or elements that promote health research in policy development exist, they remain fragmented and overwhelmed by the totality of health research in the country. This study aimed at developing a framework for promoting the utilisation of malaria research for policy development in Malawi. The framework seeks to encourage the engagement of researchers and policymakers, and to increase visibility and coordination of the existing elements presently promoting research utilisation for policy development. Methods: The study utilised both quantitative and qualitative methods depending on the study objectives. Several specific approaches were employed towards the development of the framework. The first step described the type and amount of malaria research conducted in Malawi, and its related sources of funding from 1984 to 2016. Its approach included an online systematic literature review in the Medline/PubMed database for Malawian publications, and the extraction of approved malaria studies from two Ethical Committees. The second approach assessed the research contribution to malaria policy development and the understanding of policy formulation process in Malawi. This step was done through case studies that adopted systematic literature search, in-depth interviews with key informants and relevant stakeholders, and record review. The third step examined the facilitating factors and barriers to utilisation of malaria research in the policy development process and involved in-depth interview with key informants, and review of records. In addition, the assessment of challenges to the implementation of malaria policies in Malawi was conducted through in-depth interviews with key informants and key stakeholders. The development of the framework was then guided by the lessons from the case studies and findings from the assessment of facilitating factors and barriers while being informed by literature of existing research-to-policy frameworks. In addition, a rigorous iterative approach with stakeholders was conducted for validation and applicability of the framework. Findings: The research revealed that clinical and basic research in the fields of malaria in pregnancy, severe malaria, and vector and/or agent dynamics dominated the publications while morbidity studies, severe malaria, and health policy and systems research dominated the approved studies. The results show that malaria research output increased steadily from 1996 to 2016 and this was attributed to the establishment of the College of Medicine and its research affiliates. However, the major malaria research funding came from external sources. The case studies showed that primary research was instrumental in changing the malaria treatment policies and in some cases Malawi was the first country to adopt these changes. Policy development process was found to follow the established process that involves agenda setting, policy formulation, and policy implementation. Many factors were identified as facilitating the utilisation of malaria research in policy development and these included the government commitment through the ministry of health, by reviving the policy development unit and the establishment of the office for the director of research, the knowledge translation unit, and academic and non-academic research institutions. Specific tools that support these institutions are the national health research agenda, guidelines for policy development and analysis, and guidelines for evidence use in policy-making. Barriers to the utilisation of malaria research included, the lack of knowledge by researchers to involve, collaborate and communicate their research findings to policy makers. Other barriers included lack of platforms for researcher-public engagement, politics, funder driven research, unknown World Health Organization policy position, and the lack of a malaria research repository. Challenges to the implementation of malaria policies included inadequate resources, unavailability of trained staff, poor supervision and mentorship, politics, parallel implementation of policies, lack of a platform for engagement with communities, top-down approach in policy development, lack of understanding of socio-cultural factors affecting policy uptake by communities, and incomplete stakeholder analysis during policy development. Lessons from the case studies and the assessment of facilitating factors and barriers contributed to the development of a contextual knowledge-to-policy framework which proposes an integrated approach to knowledge translation between malaria researchers and the government, through the Ministry of Health (MOH) and the National Malaria Control Programme (NMCP), which is considered as the main user of research knowledge. Conclusion: Malaria research provides the relevant evidence for policy decision-making to address the malaria burden in Malawi. The developed framework offers a basis for the identified factors and their linkages to promote a coordinated approach to malaria research utilisation in policy making. Its applicability and success would, however, hinge on its wider dissemination and ownership by the government through the NMCP. It is important for the government to support health policy and systems research that seeks to explore bottlenecks in the delivery of health services within the health system. This evidence should provide solutions to challenges of policy implementation. / Thesis (PhD)--University of Pretoria, 2017. / University of Pretoria Institute for Sustainable Malaria Control (UP ISMC) and MRC Collaborating Centre for malaria research / School of Health Systems and Public Health (SHSPH) / PhD / Unrestricted

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L'accès aux médicaments essentiels (ME) est un élément clé de la qualité des soins dans un système de santé. Par ailleurs, le financement basé sur la performance (FBP) attire de plus en plus l'attention des décideurs comme une intervention pour améliorer la prestation des services de santé, y compris l’accès aux ME, dans les pays à faible et moyen revenus (PFMR). Malgré l’intérêt croissant de la recherche sur le FBP, très peu d’étude ont porté sur la mise à l’agenda d’une telle réforme ou son maintien à l’ordre du jour au fil du temps, encore moins sur l’influence de celle-ci sur l’accès aux ME dans les PFMR. A travers une analyse du programme de FBP au Cameroun, la présente thèse vise à faire avancer les connaissances en examinant les questions suivantes : qu’est-ce qui explique l’apparition du FBP au niveau de la politique nationale de la santé et quel est l’impact de ce programme sur l’accès aux ME? Le devis de recherche est celui d’une étude de cas et la démarche analytique s’appuie sur la combinaison des données qualitatives, à travers des entrevues réalisées auprès des acteurs clés du programme FBP au Cameroun, et quantitatives, issues de l’évaluation d’impact de ce programme. La perspective conceptuelle est celle des cycles de politique, du cadre de transfert des politiques et de la recherche interventionnelle. Les résultats sont structurés en quatre articles scientifiques. La mise du FBP à l’agenda au Cameroun s’est construite à partir des rapports et événements identifiant l'absence d'une politique de financement de la santé adaptée comme une question importante à laquelle il fallait s'attaquer (article 1). L'évolution du discours politique vers une plus grande responsabilisation a permis de tester de nouveaux mécanismes. Un groupe d'entrepreneurs politiques de la Banque mondiale, par le biais de nombreuses formes d'influence (financière, conceptuelle, fondée sur la connaissance et les réseaux) et en s'appuyant sur plusieurs réformes en cours, a collaboré avec de hauts fonctionnaires du gouvernement pour mettre le programme FBP à l'ordre du jour. Des organisations non gouvernementales internationales ont été recrutées au début du programme pour assurer sa mise en œuvre rapide. Toutefois, il a fallu transférer ce rôle aux organisations nationales pour assurer la pérennité, l'appropriation et l'intégration de l'intervention du FBP dans le système de santé (article 2). L'expérience de ce transfert montre que les éléments favorisant la réussite d’un tel processus incluent des directives structurées, une appropriation et planification conjointe de la transition par toutes les parties, et un soutien post-transition aux nouveaux acteurs. Les données qualitatives suggèrent que la mise en œuvre du programme FBP influence l’accès aux médicaments essentiels par l’entremise de plusieurs facteurs, notamment une plus grande autonomie des formations sanitaires, une régulation appliquée des équipes cadre de santé, une plus grande responsabilisation des acteurs du médicament et la libéralisation du système d’approvisionnement (article 3). Cependant, le programme a eu un impact très limité sur la disponibilité des ME (article 4). L'intervention n’a été associée à aucune réduction des ruptures de stock de ME, sauf pour la planification familiale (PF), avec une hétérogénéité des effets entre les régions et les zones urbaines et rurales. Ces résultats sont la conséquence d'un échec partiel de la mise en œuvre de ce programme, allant de la perturbation et de l'interruption des services à une autonomie limitée des formations sanitaires dans la gestion des décisions et à un retard considérable dans le paiement des prestations. / Access to essential medicines (EM) is a key element of quality of care in a health system. Accordingly, performance-based financing (PBF) is increasingly attracting the attention of policy makers as a promising intervention to improve health service delivery, including access to essential medicines, in low and middle-income countries (LMICs). Despite the growing interest in PBF research, very few studies have focused on how such a reform has been put on the agenda or how it has been maintained over time, much less how it has influenced access to EMs in low- and middle-income countries. Through an analysis of the PBF program in Cameroon, this thesis aims to advance knowledge by examining the following questions: What explains the emergence of PBF at the level of national health policy and what is the impact of this program on access to EMs? The research design is a case study and the analytical approach is based on a combination of qualitative data, through interviews conducted with key actors of the PBF program in Cameroon, and quantitative data from the impact evaluation of this program. The conceptual perspective is that of policy cycles, the policy transfer framework and intervention research. The results are structured into four scientific articles. Putting the PBF on the agenda in Cameroon was built from reports and events identifying the lack of an appropriate health financing policy as a critical issue that needed to be addressed (article 1). The evolution of political discourse towards greater accountability made it possible to test new mechanisms. A group of political entrepreneurs from the World Bank, through many forms of influence (financial, conceptual, knowledge-based and networked) and building on several ongoing reforms, worked with senior government officials to put the PBF reform on the agenda. International non-governmental organizations were recruited at the beginning of the programme to ensure its rapid implementation. However, this role had to be transferred to national organizations to ensure sustainability, ownership and integration of the PBF intervention into the health system (Article 2). The experience of this transfer shows that the elements for the success of such a process include structured guidelines, joint ownership and planning of the transition by all parties, and post-transition support to new actors. The implementation of the PBF programme influences access to essential medicines through several factors, including greater autonomy of health v facilities, enforced regulation of district medical teams, greater accountability of drug stakeholders and liberalization of the supply system (Article 3). However, the programme had a very limited impact on the availability of EMs (Article 4). The intervention was not associated with any reduction in EM stock-outs, except for family planning (FP), where the reduction was 34% (P = 0.028), with a heterogeneity of effects between regions and urban and rural areas. These poor results were likely the consequence of partial implementation failure, ranging from disruption and discontinuation of services to limited facility autonomy in managing decision‐making and considerable delay in performance payment.